=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861808784
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL FOOT SPECIALITIES P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2014
-----------------------------------------------------
Last Update Date | 07/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8190 ROYAL PALM BLVD STE 203
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-5706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-346-5077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8190 ROYAL PALM BLVD STE 203
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-5706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-346-5077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DERYCK ROMEO FERNANDEZ
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 954-346-5077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO3674
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------